Goniometry of upper limb

Goniometry of upper limb

1. GONIOMETER Name – priyal sharma Roll no. - 28 Course – bpt ii nd year

2. Index Introduction to Goniometry Muscle length testing Shoulder complex Elbow joint Wrist joint First carpometacarpal joint Joints of fingers

3. Definition The term goniometry is derived from two Greek words: gonia , meaning “angle,” and metron , meaning “measure.” Therefore, goniometry refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body. The examiner obtains these measurements by placing the parts of the measuring instrument, called a goniometer, along the bones immediately proximal and distal to the joint being evaluated. Goniometry is used to measure and document the amount of active and passive joint motion as well as abnormal fixed joint positions.

4. Example: The elbow joint is evaluated by placing the parts of the measuring instrument on the humerus (proximal segment) and the forearm (distal segment) and measuring either a specific joint position or the total arc of motion The left upper extremity of an individual in the supine position is shown. The parts of the measuring instrument have been placed along the proximal (humerus) and distal (radius) body segments and centered over the axis of the elbow joint. When the distal segment has been moved toward the proximal segment (elbow flexion), a measurement of the arc of motion can be obtained.

5. Uses of Goniometry Goniometric data used in conjunction with other information can provide a basis for the following: • Determining the presence, absence, or change in impairment • Establishing a diagnosis • Developing a prognosis, treatment goals, and plan of care • Evaluating progress or lack of progress toward rehabilitative goals • Modifying treatment • Motivating the individual • Researching the effectiveness of therapeutic techniques or regimens (for example, measuring outcomes following exercises, medications, and surgical procedures) • Fabricating orthotics and adaptive equipment

6. Muscle length testing Maximal muscle length is the greatest extensibility of a muscle-tendon unit. It is the maximal distance between the proximal and the distal attachments of a muscle to bone. Clinically, muscle length is not measured directly; instead, it is measured indirectly by determining the maximal passive ROM of the joint(s) crossed by the muscle. Muscle length, in addition to the integrity of the joint surfaces and the extensibility of the capsule, ligaments, fascia, and skin, affects the amount of passive ROM of a joint. The purpose of testing muscle length is to ascertain whether hypomobility or hypermobility is caused by the length of the inactive antagonist muscle or other structures.

7. Example: The triceps is a two-joint muscle that extends the elbow and shoulder. The triceps is passively insufficient during full shoulder flexion and full elbow flexion. When an examiner assesses elbow flexion ROM, the shoulder must be in a neutral position so there is sufficient length in the triceps to allow full flexion at the elbow. During the measurement of elbow flexion ROM, the shoulder must be in neutral to avoid passive insufficiency of the triceps, which would limit the ROM Muscle length testing of upper extremity

8. Muscles can be categorized by the number of joints they cross from their proximal to their distal attachments. One joint muscles cross and therefore influence the motion of only one joint. Two-joint muscles cross and influence the motion of two joints, whereas multi-joint muscles cross and influence multiple joints. In contrast to one-joint muscles, the length of two-joint and multi-joint muscles is usually not sufficient to allow full passive ROM to occur simultaneously at all joints crossed by these muscles. This inability of a muscle to lengthen and allow full ROM at all of the joints the muscle crosses is termed pas sive insufficiency .. If a two-joint or multi-joint muscle crosses a joint that the examiner is assessing for ROM, the individual must be positioned so that passive tension in the muscle does not limit the joint’s ROM. To allow full ROM at the joint under consideration and to ensure sufficient length in the muscle, the muscle must be put on slack at all of the joints the muscle crosses that are not being assessed. A muscle is put on slack by passively approximating the origin and insertion of the muscle .

9. SHOULDER COMPLEX – INTRODUCTION The shoulder complex is composed of four joints: the glenohumeral (GH), sternoclavicular (SC), acromioclavicular (AC), and scapulothoracic joints. Full range of motion (ROM) of the shoulder requires coordinated motion at all four of these joints. About two- thirds of shoulder ROM occurs at the glenohumeral joint and one- third occurs at the remaining joints.

10. Glenohumeral joint Osteokinematics Flexion / extension in sagittal plane Abduction / Adduction in frontal plane Medial / Lateral rotation transverse plane Arthrokinematics Spin (pure flexion and extension) Inferior glide (Abduction) Superior glide (Adduction) Posterior glide (Medial rotation) Anterior glide (Lateral rotation)  The greatest restriction of passive motion is in lateral rotation, followed by some restriction in abduction and less restriction in medial rotation.

11. Acromioclavicular (AC) Joint Osteokinematics Flexion / extension Abduction / adduction Medial / lateral rotation  Arthrokinematics Posterior / anterior spin Inferior / superior spin Anterior / posterior glide

12. Scapulothoracic (ST) Joint Scapulothoracic complex movements: Elevation and protraction = anterior elevation Elevation and retraction = posterior elevation Depression and protraction = anterior depression Depression and retraction = posterior depression The movement of the scapula along the thoracic cage also directly influences the biomechanics of the shoulder complex as a whole, and can moreover predispose the development of impingement syndrome. The healthy movement of the scapula along the thorax during arm elevation includes protraction, posterior tilting, and lateral rotation, depending on the plane of movement

13. Sternoclavicular joint Osteokinematics The SC joint has 3 degrees of freedom, and motion consists of movement of the clavicle on the sternum elevation–depression in the frontal plane protraction–retraction in the horizontal plane, anterior–posterior rotation around the longitudinal axis through the length of the clavicle.

14. Flexion of shoulder joint Plane – sagittal cardinal plane Axis – around medial – lateral axis Normal ROM - shoulder complex flexion :-adults vary from about 165 to 180 degrees glenohumeral flexion :- for adults vary from about 100 to 115 degrees Testing position – place the individual supine with the knees flexed to flatten the lumbar spine. Position the shoulder in 0 degrees of abduction, adduction, and rotation. Place the elbow in extension so that tension in the long head of the triceps muscle does not limit the motion. Position the forearm in 0 degrees of supination and pronation so that the palm of the hand faces the body. Stabilization – 1) glenohumeral flexion – Stabilize the scapula to prevent posterior tilting, upward rotation, and elevation of the scapula 2) Shoulder complex flexion - Stabilize the thorax to prevent extension of the spine and movement of the ribs.

15. Testing Motion - Flex the shoulder by lifting the humerus off the examining table, bringing the hand up over the individual’s head. Maintain the extremity in neutral abduction and adduction during the motion. Slight rotation is allowed to occur as needed to attain maximal flexion. Glenohumeral Flexion The end of glenohumeral flexion ROM occurs when resistance to further motion is felt and attempts to overcome the resistance cause upward rotation, posterior tilting, or elevation of the scapula. Shoulder Complex Flexion The end of shoulder complex flexion ROM occurs when resistance to further motion is felt and attempts to overcome the resistance cause extension of the spine or motion of the ribs Goniometer alignment - This goniometer alignment is used for measuring glenohumeral and shoulder complex flexion Center fulcrum of the goniometer over the lateral aspect of the greater tubercle. Align proximal arm parallel to the midaxillary line of the thorax. Align distal arm with the lateral midline of the humerus. Depending on how much flexion and rotation occur, the lateral epicondyle of the humerus or the olecranon process of the ulnar may be helpful references.

16. Flexion goniometer alignment The alignment of the goniometer at the beginning of glenohumeral and shoulder complex flexion ROM The alignment of the goniometer at the end of glenohumeral flexion ROM. The examiner’s hand supports the individual’s extremity and maintains the goniometer’s distal arm in correct alignment over the lateral epicondyle. The examiner’s other hand releases its stabilization and aligns the goniometer’s proximal arm with the lateral midline of the thorax. The alignment of the goniometer at the end of shoulder complex flexion ROM. More motion is noted during shoulder complex flexion than in glenohumeral flexion

17. Normal End-feel - Glenohumeral Flexion The end- feel is fi rm because of tension in the posterior band of the coracohumeral ligament; the posterior joint capsule; and the posterior deltoid, teres minor, teres major, and infraspinatus muscles. Shoulder Complex Flexion The end- feel is fi rm because of tension in the costoclavicular ligament and SC capsule and ligaments, and the latissimus dorsi, sternocostal fibers of the pectoralis major and pectoralis minor, and rhomboid major and minor muscles

18. Extension of shoulder joint Plane – sagittal plane Axis – medial – lateral axis Normal ROM – shoulder complex :- for adults vary from about 50 to 60 degrees glenohumeral extension :- for adults vary from about 20 to 25 degrees Testing position – 1)Place the shoulder in 0 degrees of abduction, adduction, and rotation. Position the elbow in slight flexion so that tension in the long head of the biceps brachii muscle will not restrict the motion. 2) Place the forearm in 0 degrees of supination and pronation so that the palm of the hand faces the body Stabilization – Glenohumeral Extension Stabilize the scapula at the inferior angle or at the acromion and coracoid processes to prevent elevation and anterior tilting (inferior angle moves posteriorly) of the scapula . Shoulder Complex Extension The examining table and the weight of the trunk stabilize the thorax to prevent forward flexion of the spine. The examiner can also stabilize the trunk to prevent rotation of the spine.

19. Goniometer alignment This goniometer alignment is used for measuring glenohumeral and shoulder complex extension Center fulcrum of the goniometer over the lateral aspect of the greater tubercle Align proximal arm parallel to the midaxillary line of the thorax. Align distal arm with the lateral midline of the humerus, using the lateral epicondyle of the humerus for reference Normal End-feel Glenohumeral Extension - The end- feel is firm because of tension in the anterior band of the coracohumeral ligament; anterior joint capsule; and clavicular fibers of the pectoralis major, coracobrachialis, and anterior deltoid muscles. Shoulder Complex Extension The end- feel is fi rm because of tension in the SC capsule and ligaments and in the serratus anterior muscle.

20. Extension goniometer alignment The alignment of the goniometer at the beginning of glenohumeral and shoulder complex extension ROM The alignment of the goniometer at the end of glenohumeral extension ROM. The examiner’s left hand supports the individual’s extremity and holds the distal arm of the goniometer in correct alignment over the lateral epicondyle of the humerus. The alignment of the goniometer at the end of shoulder complex extension ROM. The examiner’s hand that formerly stabilized the individual’s trunk now positions the goniometer

21. ABDUCTION of shoulder joint Plane – frontal plane Axis – anterior – posterior axis Normal ROM - shoulder complex abduction :- for adults vary from about 170 to 180 degrees Glenohumeral abduction :- for adults vary from about 90 to 125 degrees Testing position – Position the individual supine, with the shoulder in lateral rotation and 0 degrees of flexion and extension so that the palm of the hand faces anteriorly. If the humerus is not laterally rotated, contact between the greater tubercle of the humerus and the upper portion of the glenoid fossa or the acromion process will restrict the motion. The elbow should be extended so that tension in the long head of the triceps does not restrict the motion Stabilization Glenohumeral Abduction:- Stabilize the scapula to prevent upward rotation and elevation of the scapula Shoulder Complex Abduction:- Stabilize the thorax to prevent lateral fl exion of the spine. The weight of the trunk may assist stabilization

22. ABDUCTION Goniometer Alignment The alignment of the goniometer at the beginning of glenohumeral and shoulder complex abduction ROM The alignment of the goniometer at the end of glenohumeral abduction ROM. The examining table or the examiner’s hand can support the individual’s extremity and align the goniometer’s distal arm with the anterior midline of the humerus. The examiner’s other hand has released its stabilization of the scapula and is holding the proximal arm of the goniometer parallel to the sternum The alignment of the goniometer at the end of shoulder complex abduction ROM. The humerus has laterally rotated, and the medial epicondyle is now a helpful anatomical landmark for aligning the distal arm of the goniometer. Note that the placement of the stationary and moving arms of the goniometer with the proximal and distal joint segments have inadvertently been switched from that in Figure 4.23, but both placements will give an accurate measurement of the angle at the end of motion

23. Goniometer alignment - This goniometer alignment is used for measuring glenohumeral and shoulder complex abduction 1. Center fulcrum of the goniometer close to the anterior aspect of the acromial process. 2. Align proximal arm so that it is parallel to the midline of the anterior aspect of the sternum. 3. Align distal arm with the anterior midline of the humerus. Depending on the amount of abduction and lateral rotation that has occurred, the medial epicondyle may be a helpful reference Normal end-feel Glenohumeral Abduction The end- feel is usually fi rm because of tension in the middle and inferior bands of the glenohumeral ligament, inferior joint capsule, and the teres major and clavicular fibers of the pectoralis major muscles. Shoulder Complex Abduction The end- feel is fi rm because of tension in the costoclavicular ligament; sternoclavicular capsule and ligaments; and latissimus dorsi, sternocostal fibers of the pectoralis major, and major and minor rhomboid muscles.

24. ADDUCTION of shoulder joint Plane – FRONTAL PLANE Axis – anterior posterior axis Adduction in the frontal plane is not usually measured and recorded because it is the return to the zero starting position from full abduction. Further adduction can occur if the arm is positioned anterior to the body so that contact is avoided, but in that case adduction is combined with shoulder flexion.

25. MEDIAL ROTATION of shoulder joint Plane - transverse plane Axis - vertical axis Normal ROM - ROM values for adults vary from about 70 to 90 degrees. Normal glenohumeral medial rotation ROM values for adults vary from about 50 to 60 degrees. Testing position - Position the individual supine, with the arm being tested in 90 degrees of shoulder abduction. Place the forearm perpendicular to the supporting surface and in 0 degrees of supination and pronation so that the palm of the hand faces the feet. Rest the full length of the humerus on the examining table. STABILIZATION -The elbow is not supported by the examining table. Place a pad under the humerus so that the humerus is level with the acromion process- Stabilization Glenohumeral Medial Rotation In the beginning of the ROM, stabilization is often needed at the distal end of the humerus to keep the shoulder in 90 degrees of abduction. Toward the end of the ROM, the clavicle and coracoid and acromion processes of the scapula are stabilized to prevent anterior tilting and protraction of the scapula. Shoulder Complex Medial Rotation Stabilization is often needed at the distal end of the humerus to keep the shoulder in 90 degrees of abduction. The thorax may be stabilized by the weight of the individual’s trunk or with the examiner’s hand to prevent fl exion or rotation of the spine

26. Goniometer alignment -This goniometer alignment is used for measuring glenohumeral and shoulder complex medial rotation 1. Center fulcrum of the goniometer over the olecranon process. 2. Align proximal arm so that it is either perpendicular to or parallel with the floor. 3. Align distal arm with the ulna, using the olecranon process and ulnar styloid for reference Normal End-feel - Glenohumeral Medial Rotation The end- feel is firm because of tension in the posterior joint capsule and the infraspinatus and teres minor muscles. Shoulder Complex Medial Rotation The end- feel is fi rm because of tension in the sternoclavicular capsule and ligaments, the costoclavicular ligament, and the major and minor rhomboid and trapezius muscles

27. Goniometer Alignment of Med Rotation The alignment of the goniometer at the beginning of medial rotation ROM of the glenohumeral and shoulder complex. The alignment of the goniometer at the end of medial rotation ROM of the glenohumeral joint. The examiner uses one hand to support the individual’s forearm and the distal arm of the goniometer. The examiner’s other hand holds the body and the proximal arm of the goniometer The alignment of the goniometer at the end medial rotation ROM of the shoulder complex

28. Lateral Rotation of Shoulder Joint Plane – sagittal plane Axis – medial lateral (coronal) axis Normal ROM - shoulder complex lateral rotation ROM values for adults vary from about 90 to 100 degrees . Normal glenohumeral lateral rotation ROM values for adults vary from about 80 to 90 degrees. Testing position - Position the individual supine, with the arm being tested in 90 degrees of shoulder abduction. Place the forearm perpendicular to the supporting surface and in 0 degrees of supination and pronation so that the palm of the hand faces the feet. Rest the full length of the humerus on the examining table. The elbow is not supported by the examining table. Place a pad under the humerus so that the humerus is level with the acromion process Stabilization – Glenohumeral Lateral Rotation At the beginning of the ROM, stabilization is often needed at the distal end of the humerus to keep the shoulder in 90 degrees of abduction. Toward the end of the ROM, the spine of the scapula is stabilized to prevent posterior tilting and retraction. Shoulder Complex Lateral Rotation Stabilization is often needed at the distal end of the humerus to keep the shoulder in 90 degrees of abduction. To prevent extension or rotation of the spine, the thorax may be stabilized by the weight of the individual’s trunk or by the examiner’s hand.

29. Goniometer alignment - This goniometer alignment is used for measuring glenohumeral and shoulder complex lateral rotation . Center fulcrum of the goniometer over the olecranon process Align proximal arm so that it is either parallel to or perpendicular to the floor. Align distal arm with the ulna, using the olecranon process and ulnar styloid for reference. Normal End-Feel - Glenohumeral Lateral Rotation The end- feel is fi rm because of tension in the anterior joint capsule; the three bands of the glenohumeral ligament; the coracohumeral ligament; and the subscapularis, the teres major, and the clavicular fi bers of the pectoralis major muscles. Shoulder Complex Lateral Rotation The end- feel is fi rm because of tension in the SC capsule and ligaments and in the latissimus dorsi, sternocostal fi bers of the pectoralis major, pectoralis minor, and serratus anterior muscles

30. Goniometer alignment of Lat Rotation The alignment of the goniometer at the beginning of lateral rotation ROM of the glenohumeral joint and shoulder complex The alignment of the goniometer at the end of lateral rotation ROM of the glenohumeral joint. The examiner’s hand supports the individual’s forearm and the distal arm of the goniometer. The examiner’s other hand holds the body and proximal arm of the goniometer. The placement of the examiner’s hands would be reversed if the right shoulder was being tested The alignment of the goniometer at the end of lateral rotation ROM of the shoulder complex

31. Elbow Joint – Introduction Humeroulnar and Humeroradial Joints Osteokinematics flexion– extension occurs in the sagittal plane around a medial–lateral (coronal) axis Arthrokinematics - posterior sliding of the concave trochlear notch of the ulna on the convex trochlea of the humerus continues during extension until the ulnar olecranon process enters the humeral olecranon fossa.

32. Superior and Inferior Radioulnar Joints Osteokinematics - pronation and supination Arthrokinematic At the superior radioulnar joint, the convex rim of the radial head spins within the annular ligament and the concave radial notch of the ulna during pronation and supination At the inferior radioulnar joint, the concave surface of the ulnar notch on the radius slides over the ulnar head .

33. Flexion of Elbow Joint Plane - sagittal plane Axis – Medial – lateral axis Normal ROM - flexion ROM values for adults range from about 140 to 150 degrees Testing position – Position the individual supine with the shoulder in 0 degrees of fl exion , extension, and abduction so that the arm is close to the side of the body. Place a pad or towel roll under the distal end of the humerus to allow full elbow extension. Position the forearm in full supination with the palm of the hand facing the ceiling. Stabilization - Stabilize the humerus to prevent fl exion of the shoulder. The pad under the distal humerus and the examining table prevents extension of the Normal END-FEEL - Usually the end-feel is soft because of compression of the muscle bulk of the anterior forearm with that of the anterior upper arm. If the muscle bulk is small, the end-feel may be hard because of contact between the coronoid process of the ulna and the coronoid fossa of the humerus, and because of contact between the head of the radius and the radial fossa of the humerus. The end-feel may be fi rm because of tension in the posterior joint capsule, the lateral and medial heads of the triceps muscle, and the anconeus muscle

34. Goniometer Alignment – 1. Center fulcrum of the goniometer over the lateral epicondyle of the humerus. 2. Align proximal arm with the lateral midline of the humerus, using the center of the acromion process for reference. 3. Align distal arm with the lateral midline of the radius, using the radial head and radial styloid process for reference Alignment of the goniometer at the beginning of elbow flexion ROM. A towel is placed under the distal humerus to ensure that the supporting surface does not prevent full elbow extension Alignment of the goniometer at the end of elbow flexion ROM. The forearm is kept in full supination so that the greatest amount of elbow flexion can occur

35. Extension of elbow joint Plane - sagittal plane Axis – med- lat axis Normal ROM - . Elbow extension ROM is not usually measured and recorded separately because it is the starting position for measuring and recording elbow flexion ROM. Normal extension ROM value for adults is about 0 degrees Testing position – same as flexion Stabilization – same as flexion Goniometer Alignment – same as flexion Normal END-FEEL - Usually the end-feel is hard because of contact between the olecranon process of the ulna and the olecranon fossa of the humerus. Sometimes the endfeel is fi rm because of tension in the anterior joint capsule, the collateral ligaments, and the brachialis muscle

36. Forearm Pronation Plane – frontal plane Axis – ant- post axis Normal ROM - Normal ROM values for adults range from about 75 to 85 degrees. Testing position - Position the individual sitting with the shoulder in 0 degrees of fl exion , extension, abduction, adduction, and rotation so that the upper arm is close to the side of the body. Flex the elbow to 90 degrees and support the forearm. This testing position helps to isolate the motion to the forearm and prevent glenohumeral rotation. Initially position the forearm midway between supination and pronation so that the thumb is aligned with the humerus; in most individuals the thumb will be pointing up toward the ceiling. Stabilization - Stabilize the distal end of the humerus to prevent medial rotation and abduction of the shoulder. Normal END-FEEL - The end-feel may be hard because of contact between the ulna and the radius, or it may be fi rm because of tension in the dorsal radioulnar ligament of the inferior radioulnar joint, the interosseous membrane, and the supinator muscle

37. Goniometer Alignment - 1. Center fulcrum of the goniometer laterally and proximally to the ulnar styloid process. 2. Align proximal arm parallel to the anterior midline of the humerus. 3. Place distal arm across the dorsal surface of the forearm, just proximal to the styloid processes of the radius and ulna, where the forearm is most level and free of muscle bulk. The distal arm of the goniometer should be parallel to the styloid processes of the radius and ulna. Alignment of the goniometer in the beginning of pronation ROM. The goniometer is placed laterally to the distal radioulnar joint. The arms of the goniometer are aligned parallel to the anterior midline of the humerus 2. Alignment of the goniometer at the end of pronation ROM. The examiner uses one hand to hold the proximal arm of the goniometer parallel to the anterior midline of the humerus. The examiner’s other hand supports the forearm and assists in placing the distal arm of the goniometer across the dorsum of the forearm just proximal to the radial and ulnar styloid process. The fulcrum of the goniometer is proximal and lateral to the ulnar styloid process

38. Forearm Supination Plane –frontal plane Axis – anterior- posterior axis Normal ROM - Normal ROM values for adults range from about 80 to 90 degrees Testing position- Position the individual sitting with the shoulder in 0 degrees of fl exion , extension, abduction, adduction, and rotation so that the upper arm End of supination ROM. The examiner uses one hand to hold the elbow close to the individual’s body and in 90 degrees of elbow flexion, preventing lateral rotation and adduction of the shoulder. The examiner’s other hand pushes on the distal radius while supporting the forearm. the side of the body. Flex the elbow to 90 degrees and support the forearm. This testing position helps to isolate the motion to the forearm and prevent glenohumeral rotation. Initially position the forearm midway between supination and pronation so that the thumb is aligned with the humerus; in most individuals the thumb will be pointing up toward the ceiling. Stabilization - Stabilize the distal end of the humerus to prevent lateral rotation and adduction of the shoulder. Normal END-FEEL The end-feel is fi rm because of tension in the palmar radioulnar ligament of the inferior radioulnar joint, oblique cord, interosseous membrane, and pronator teres and pronator quadratus muscles.

39. Goniometer Alignment – Place fulcrum of the goniometer medially and just proximally to the ulnar styloid process. Align proximal arm parallel to the anterior midline of the humerus. Place distal arm across the ventral surface of the forearm, just proximal to the styloid processes, where the forearm is most level and free of muscle bulk. The distal arm of the goniometer should be parallel to the styloid processes of the radius and ulna. 1. Alignment of the goniometer at the beginning of supination ROM. The body of the goniometer is medial to the distal radioulnar joint and the arms of the goniometer are parallel to the anterior midline of the humerus 2. Alignment of the goniometer at the end of supination ROM. The examiner uses one hand to hold the proximal arm of the goniometer parallel to the anterior midline of the humerus. The examiner’s other hand supports the forearm while holding the distal arm of the goniometer across the volar surface of the forearm just proximal to the radial and ulnar styloid process. The fulcrum of the goniometer is proximal and medial to the ulnar styloid process

40. WRIST JOINT Radiocarpal and Midcarpal Joints Osteokinematics – 1) flexion–extension in the sagittal plane around a medial–lateral axis 2) d radial–ulnar deviation in the frontal plane around the anterior-posterior axis Arthrokinematics - Motion at the radiocarpal joint occurs because the convex surfaces of the proximal row of carpals roll and slide on the concave surfaces of the radius and radioulnar disc.

41. WRIST FLEXION Plane - sagittal plane Axis - medial–lateral axis Normal ROM - for adults vary from about 60 to 80 degrees Testing Position – Position the individual sitting next to a supporting surface with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the palm of the hand facing the ground. Position the individual sitting next to a supporting surface with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the palm of the hand facing the ground. If the individual cannot be positioned in 90 degrees of shoulder abduction, a more adducted shoulder position may be used, but the forearm will be in some pronation when the palm is facing the floor Stabilization - Stabilize the radius and ulna to prevent supination or pronation of the forearm and motion of the elbow. Normal END-FEEL - The end-feel is fi rm because of tension in the dorsal radiocarpal ligament and the dorsal joint capsule. Tension in the extensor carpi radialis brevis and longus and extensor carpi ulnaris muscles may also contribute to the firm end-feel

42. Goniometer Alignment – 1. Center fulcrum on the lateral aspect of the wrist over the triquetrum. 2. Align proximal arm with the lateral midline of the ulna, using the olecranon and ulnar styloid processes for reference. 3. Align distal arm with the lateral midline of the fi fth metacarpal. Do not use the soft tissue of the hypothenar eminence for reference

43. Goniometer Alignment of Wrist Flexion The alignment of the goniometer at the beginning of wrist flexion ROM At the end of wrist flexion ROM the examiner uses one hand to align the distal arm of the goniometer with the fifth metacarpal while maintaining the wrist in flexion. The examiner exerts pressure on the middle of the dorsum of the individual’s hand and avoids exerting pressure directly on the fifth metacarpal because such pressure will distort the goniometer alignment

44. WRIST EXTENSION Plane – sagittal plane Axis – medial-lateral axis Normal ROM - values for adults vary from about 60 to 75 degrees Testing Position – Position the individual sitting next to a supporting surface with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the palm of the hand facing the ground. Rest the forearm on the supporting surface, but leave the hand free to move. Avoid radial or ulnar deviation of the wrist and extension of the fingers. If the individual cannot be positioned in 90 degrees of shoulder abduction, a more adducted shoulder position may be used, but the forearm will be in some pronation when the palm is facing the floor. Stabilization - Stabilize the radius and ulna to prevent supination or pronation of the forearm and motion of the elbow. Normal END-FEEL – Usually the end-feel is fi rm because of tension in the palmar radiocarpal ligament, ulnocarpal ligament, and palmar joint capsule. . Tension in the palmaris longus, fl exor carpi radialis, and flexor carpi ulnaris muscles may also contribute to the fi rm end-feel. Sometimes the end-feel is hard because of contact between the radius and the carpal bones

45. Goniometer Alignment Center fulcrum on the lateral aspect of the wrist over the triquetrum. Align proximal arm with the lateral midline of the ulna, using the olecranon and ulnar styloid process for reference. Align distal arm with the lateral midline of the fi fth metacarpal. Do not use the soft tissue of the hypothenar eminence for reference The alignment of the goniometer at the beginning of wrist extension ROM At the end of the ROM of wrist extension, the examiner aligns the distal goniometer arm with the fifth metacarpal while holding the wrist in extension. The examiner avoids exerting excessive pressure on the fifth metacarpa l

46. WRIST RADIAL DEVIATION Plane – frontal plane Axis – anterior-posterior axis Normal ROM - for adults vary from about 20 to 25 degrees. Testing Position Position the individual sitting next to a supporting surface with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the palm of the hand facing the ground. In this position the forearm will be midway between supination and pronation. Rest the forearm and hand on the supporting surface. If the individual cannot be positioned in 90 degrees of shoulder abduction, a more adducted shoulder position may be used. If the individual cannot be positioned in 90 degrees of shoulder abduction, a more adducted shoulder position may be used. Stabilization - Stabilize the radius and ulna to prevent pronation or supination of the forearm and elbow flexion beyond 90 degrees Normal END-FEEL - Usually the end-feel is hard because of contact between the radial styloid process and the scaphoid or trapezium, but it may be fi rm because of tension in the ulnar collateral ligament, the ulnocarpal ligament, and the ulnar portion of the joint capsule. Tension in the extensor carpi ulnaris and fl exor carpi ulnaris muscles may also contribute to the fi rm end-feel.

47. Goniometer Alignment – Center fulcrum on the dorsal aspect of the wrist over the capitate. Align proximal arm with the dorsal midline of the forearm. If the shoulder is in 90 degrees of abduction and the elbow is in 90 degrees of fl exion , the lateral epicondyle of the humerus can be used for reference Align distal arm with the dorsal midline of the third metacarpal. Do not use the third phalanx for reference The alignment of the goniometer at the beginning of radial deviation ROM. The examining table can be used to support the hand. The alignment of the goniometer at the end of radial deviation ROM. The examiner must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the ulnar side of the wrist, there will be an incorrect measurement of excessive radial deviation

48. WRIST ULNAR DEVIATION Plane – frontal axis Axis – anterior-posterior axis Normal ROM - for adults vary from about 30 to 40 degrees Testing Position – Position the individual sitting next to a supporting surface with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the palm of the hand facing the ground. In this position the forearm will be midway between supination and pronation. If the individual cannot be positioned in 90 degrees of shoulder abduction, a more adducted shoulder position may be used. However, the bony landmark of the lateral epicondyle of the humerus will not be accurate for aligning the proximal arm of the goniometer. Stabilization - Stabilize the radius and ulna to prevent pronation or supination of the forearm and less than 90 degrees of elbow flexion. Normal END-FEEL - The end-feel is firm because of tension in the radial collateral ligament and the radial portion of the joint capsule. Tension in the extensor pollicis brevis and abductor pollicis longus muscles may contribute to the fi rm end-feel

49. Goniometer Alignment – Center fulcrum on the dorsal aspect of the wrist over the capitate. Align proximal arm with the dorsal midline of the forearm. If the shoulder is in 90 degrees of abduction and the elbow is in 90 degrees of flexion, the lateral epicondyle of the humerus can be used for reference Align proximal arm with the dorsal midline of the forearm. If the shoulder is in 90 degrees of abduction and the elbow is in 90 degrees of flexion, the lateral epicondyle of the humerus can be used for reference The alignment of the goniometer at the beginning of ulnar deviation ROM. Sometimes if a half-circle goniometer is used, the proximal and distal arms of the goniometer will have to be reversed so that the pointer remains on the body of the goniometer at the end of the ROM. The alignment of the goniometer at the end of the ulnar deviation ROM. The examiner must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the radial side of the wrist, there will be an incorrect measurement of excessive ulnar deviation

50. Fingers: Metacarpophalangeal Joints Osteokinematics flexion–extension in the sagittal plane plane abduction–adduction in the frontal plane Arthrokinematics The concave base of the phalanx slides and rolls on the convex head of the metacarpal in the same direction as movement of the shaft of the phalanx 6 During flexion, the base of the phalanx slides and rolls anteriorly toward the palm, whereas during extension the base of the phalanx slides and rolls dorsally. In abduction, the base of the phalanx slides and rolls in the same direction as the movement of the finger.

51. Fingers: Proximal Interphalangeal and Distal Interphalangeal Joints Osteokinematics flexion–extension in the sagittal plane. Arthrokinematics Motion of the joint surfaces includes a sliding and rolling of the concave base of the more distal phalanx on the convex head of the proximal phalanx. Sliding and rolling of the base of the moving phalanx occurs in the same direction as the movement of the shaft. For example, in PIP flexion the base of the middle phalanx slides and rolls toward the palm. In PIP extension, the base of the middle phalanx slides and rolls toward the dorsum of the hand.

52. Thumb: Carpometacarpal Joint Osteokinematics – flexion–extension in the frontal plane parallel to the palm, abduction–adduction in the sagittal plane perpendicular to the plane Arthrokinematic s- The concave joint surface of the first metacarpal slides and rolls on the convex surface of the trapezium in the same direction as the metacarpal shaft to produce flexion–extension To produce abduction–adduction, the convex joint surface of the first metacarpal slides on the concave portion of the trapezium in the opposite direction to the shaft of the metacarpal

53. Thumb: Metacarpophalangeal Joint Osteokinematics - flexion–extension and a minimal amount of abduction–adduction Arthrokinematic s - At the MCP joint the concave base of the proximal phalanx slides and rolls on the convex head of the first metacarpal in the same direction as the shaft of the phalanx . The base of the proximal phalanx moves toward the palmar surface of the thumb in flexion and toward the dorsal surface of the thumb in extension.

54. Thumb: Interphalangeal Joint Osteokinematics - The IP joint is a synovial hinge joint with 1 degree of freedom: flexion–extension. Arthrokinematic s – At the IP joint of the thumb the concave base of the distal phalanx slides and rolls on the convex head of the proximal phalanx, in the same direction as the shaft of the phalanx. The base of the distal phalanx moves toward the palmar surface of the thumb in flexion and toward the dorsal surface of the thumb in extension.

55. FINGER - METACARPOPHALANGEAL JOINT FLEXION Plane – sagittal plane Axis – media-lateral axis Normal ROM - from 90 to 100 degrees Testing Position – Place the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm midway between pronation and supination, the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation and the MCP joint in a neutral position relative to abduction and adduction. Avoid extreme flexion of the PIP and DIP joints of the finger being examined. Stabilization - Stabilize the metacarpal to prevent wrist motion. Do not hold the MCP joints of the other fingers in Stabilize the metacarpal to prevent wrist motion. Do not hold the MCP joints of the other fingers in Normal END-FEEL - The end-feel may be hard because of contact between the palmar aspect of the proximal phalanx and the metacarpal, or it may be fi rm because of tension in the dorsal joint capsule and the collateral ligaments.

56. Goniometer Alignment Center fulcrum of the goniometer over the dorsal aspect of the MCP joint. Align proximal arm over the dorsal midline of the metacarpal. Align distal arm over the dorsal midline of the proximal phalanx The alignment of the goniometer at the beginning of metacarpophalangeal (MCP) flexion range of motion. In this photograph, the examiner is using a 6-inch plastic goniometer in which the arms have been trimmed to approximately 2 inches to make it easier to align over the small joints of the hand. At the end of metacarpophalangeal (MCP) flexion range of motion, the examiner uses one hand to hold the proximal goniometer arm in alignment and to stabilize the individual’s metacarpal. The examiner’s other hand maintains the proximal phalanx in MCP flexion and aligns the distal goniometer arm.

57. FINGER - METACARPOPHALANGEAL EXTENSION Plane – sagittal plane Axis – medial-lateral axis Normal ROM - range from about 20 to 45 degrees Testing Position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm midway between pronation and supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in a neutral position relative to abduction and adduction. .Avoid extension or extreme flexion of the PIP and DIP joints of the finger being tested. (If the PIP and DIP joints are positioned in extension, tension in the flexor digitorum superficialis and profundus muscles may restrict the motion. If the PIP and DIP joints are positioned in full flexion, tension in the lumbrical, dorsal interossei, and palmar interossei muscles will restrict the motion. Stabilization – Stabilize the metacarpal to prevent wrist motion. Do not hold the MCP joints of the other fingers in full flexion because tension in the transverse metacarpal ligament will restrict the motion Normal END-FEEL - The end-feel is fi rm because of tension in the palmar joint capsule and in the palmar plate.

58. Goniometer alignment – Center fulcrum of the goniometer over the dorsal aspect of the MCP joint. Align proximal arm over the dorsal midline of the metacarpal. Align distal arm over the dorsal midline of the proximal phalanx. A full-circle, 6-inch plastic goniometer is being used to measure the beginning range of motion for metacarpophalangeal (MCP) extension. The proximal arm of the goniometer is slightly longer than necessary for optimal alignment. If a goniometer of the right size is not available, the examiner can cut the arms of a plastic model to a suitable length The alignment of the goniometer at the end of metacarpophalangeal (MCP) extension. The body of the goniometer is aligned over the dorsal aspect of the MCP joint, whereas the goniometer arms are aligned over the dorsal aspect of the metacarpal and proximal phalanx

59. FINGER - METACARPOPHALANGEAL ABDUCTION Plane - frontal plane Axis - anterior–posterior axis Normal ROM – maximal range of abduction–adduction is 25 degrees No research studies to establish normal abduction ROM values measured with a universal goniometer at the MCP joint have been noted. Testing Position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; the forearm in full pronation so that the palm of the hand faces the ground; and the MCP joint in 0 degrees of flexion and extension Stabilization - Stabilize the metacarpal to prevent wrist motions. Normal END-FEEL - The end-feel is fi rm because of tension in the collateral ligaments of the MCP joints, the fascia of the web space between the fingers, and the palmar interossei muscles..

60. Goniometer Alignment – Center fulcrum of the goniometer over the dorsal aspect of the MCP joint. Align proximal arm over the dorsal midline of the metacarpal. Align distal arm over the dorsal midline of the proximal phalanx. The alignment of the goniometer at the beginning of metacarpophalangeal abduction range of motion. At the end of metacarpophalangeal (MCP) abduction, the examiner aligns the arms of the goniometer with the dorsal midline of the metacarpal and proximal phalanx rather than with the contour of the hand and finger.

61. FINGER - METACARPOPHALANGEAL ADDUCTION Plane - frontal plane Axis - anterior– posterior axis Normal ROM - very little adduction ROM beyond the 0 starting position. At the end of adduction ROM the medial–lateral aspects of the fingers are in contact with the adjoining fingers The testing position, stabilization, and goniometer alignment are similar to measuring MCP abduction.

62. FINGER - PROXIMAL INTERPHALANGEAL FLEXION Plane – sagittal plane Axis – medial-lateral axis Normal ROM - Normal ROM values for adults range from 100 to 110 degrees. Proximal interphalangeal flexion ROM is similar for all the fingers. Testing Position – Place the individual sitting, with the forearm and hand resting on a supporting surface. Position the forearm in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. (If the wrist and MCP joints are positioned in full flexion, tension in the extensor digitorum communis, extensor indicis, or extensor digiti minimi muscles will restrict the motion. If the MCP joint is positioned in full extension, tension in the lumbrical, dorsal interossei, and palmar interossei muscles will restrict the motion.) Stabilization - Stabilize the proximal phalanx to prevent motion of the MCP joint. Normal END-FEEL - Usually, the end-feel is hard because of contact between the palmar aspect of the middle phalanx and the proximal phalanx. In some individuals, the end-feel may be soft because of compression of soft tissue between the palmar aspect of the middle and proximal phalanges. In other individuals, the end-feel may be fi rm because of tension in the dorsal joint capsule and the collateral ligaments.

63. Goniometer alignment Center fulcrum of the goniometer over the dorsal aspect of the PIP joint. Align proximal arm over the dorsal midline of the proximal phalanx. Align distal arm over the dorsal midline of the middle phalanx The alignment of the goniometer at the beginning of proximal interphalangeal (PIP) flexion range of motion. At the end of proximal interphalangeal (PIP) flexion, the examiner continues to stabilize and align the proximal goniometer arm over the dorsal midline of the proximal phalange with one hand.

64. FINGER - PROXIMAL INTERPHALANGEAL EXTENSION Plane - sagittal plane Axis - medial– lateral axis Normal ROM - Normal ROM values for adults are generally considered to be about 0 degrees,15–17 although one study has reported a mean of 7 for active and 16 degrees for passive PIP extension Testing Position - Place the individual sitting, with the forearm and hand resting on a supporting surface. Position the forearm in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. Stabilization - Stabilize the proximal phalanx to prevent motion of the MCP joint Normal END-FEEL - The end-feel is fi rm because of tension in the palmar joint capsule and palmar plate (palmar ligament).

65. Goniometer alignment Center fulcrum of the goniometer over the dorsal aspect of the PIP joint. Align proximal arm over the dorsal midline of the proximal phalanx. Align distal arm over the dorsal midline of the middle phalanx The alignment of the goniometer at the beginning of proximal interphalangeal (PIP) flexion range of motion.

66. FINGER - DISTAL INTERPHALANGEAL FLEXION Plane - sagittal plane Axis - medial–lateral axis Normal rom - Normal ROM values for adults vary from 70 to 90 degrees. Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. Place the PIP joint in approximately 70 to 90 degrees of flexion Stabilization - Stabilize the middle and proximal phalanx to prevent further flexion of the PIP joint Normal END-FEEL - The end-feel is fi rm because of tension in the dorsal joint capsule, collateral ligaments, and oblique retinacular ligament.

67. Goniometer alignment Center fulcrum of the goniometer over the dorsal aspect of the DIP joint. Align proximal arm over the dorsal midline of the middle phalanx. Align distal arm over the dorsal midline of the distal phalanx

68. Goniometer Alignment Measurement of the beginning of distal interphalangeal (DIP) flexion range of motion is being conducted by means of a half-circle plastic goniometer with 6-inch arms that have been trimmed to accommodate the small size of the DIP joint The alignment of the goniometer at the end of distal interphalangeal (DIP) flexion range of motion. Note that the fulcrum of the goniometer lies distal and dorsal to the proximal interphalangeal joint axis so that the arms of the goniometer stay in direct contact with the dorsal surfaces of the middle and distal phalanges. Distal interphalangeal flexion range of motion also can be measured by using a specialized goniometer that is placed on the dorsal surface of the middle and distal phalanges. This type of goniometer is appropriate for measuring the small joints of the fingers, thumb, and toes

69. FINGER - DISTAL INTERPHALANGEAL EXTENSION Plane - sagittal plane Axis - medial– lateral axis Normal rom - Normal ROM values for adults are generally considered to be about 0 degrees, although one study has reported a mean of 8 for active and 20 degrees for passive DIP extension. Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. Position the PIP joint in approximately 70 to 90 degrees of flexion. Stabilization - Stabilize the middle and proximal phalanx to prevent extension of the PIP joint Normal END-FEEL - The end-feel is fi rm because of tension in the palmar joint capsule and the palmar plate (palmar ligament).

70. Goniometer alignment – Center fulcrum of the goniometer over the dorsal aspect of the DIP joint. Align proximal arm over the dorsal midline of the middle phalanx. Align distal arm over the dorsal midline of the distal phalanx Measurement of the beginning of distal interphalangeal (DIP) flexion range of motion is being conducted by means of a half-circle plastic goniometer with 6-inch arms that have been trimmed to accommodate the small size of the DIP joint.

71. THUMB: CARPOMETACARPAL FLEXION Plane - frontal plane Axis - anterior– posterior axis Normal ROM - values in adults vary from about 15 to 25 degrees. Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the CMC joint of the thumb in 0 degrees of abduction. The MCP and IP joints of the thumb are relaxed in a position of slight flexion. Stabilization - Stabilize the carpals, radius, and ulna to prevent wrist motions. Movement of the wrist must be avoided as it will affect the accuracy of the ROM measurement. Normal END-FEEL - The end-feel may be soft because of contact between muscle bulk of the thenar eminence and the palm of the hand, or it may be fi rm because of tension in the dorsal joint capsule and the extensor pollicis brevis and abductor pollicis brevis muscles.

72. Goniometer alignment Center fulcrum of the goniometer over the palmar aspect of the fi rst CMC joint. Align proximal arm with the ventral midline of the radius using the ventral surface of the radial head and radial styloid process for reference. Align distal arm with the ventral midline of the first metacarpal. In the beginning position for fl exion and extension, the goniometer will indicate an angle of approximately 30 to 50 degrees rather than 0 degrees, depending on the shape of the hand and wrist position. The difference between the beginning-position degrees and the end-position degrees is the ROM. For example, a measurement that begins at 35 degrees and ends at 15 degrees should be recorded as a ROM of 0 to 20 degrees

73. Goniometer alignment The alignment of the goniometer at the beginning of carpometacarpal (CMC) flexion range of motion of the thumb. Note that the goniometer does not read 0 degrees At the end of carpometacarpal (CMC) flexion range of motion, the examiner uses the hand that was stabilizing the wrist to align the proximal arm of the goniometer with the radius. The examiner’s other hand maintains CMC flexion and aligns the distal arm of the goniometer with the first metacarpal. During the measurement, the examiner must be careful not to move the individual’s wrist further into ulnar deviation or the goniometer reading will be incorrect (too high)

74. THUMB: CARPOMETACARPAL EXTENSION Plane – frontal plane Axis - anterior–posterior axis. Normal rom - Reported ROM values for adults usually vary from 15 to 35 degrees depending on the measurement methods. Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the CMC joint of the thumb in 0 degrees of abduction. The MCP and IP joints of the thumb are relaxed in a position of slight flexion. Stabilization - Stabilize the carpals, radius, and ulna to prevent wrist motions. Movement of the wrist must be avoided as it will affect the accuracy of the ROM measurement Normal END-FEEL - Stabilize the carpals, radius, and ulna to prevent wrist motions. Movement of the wrist must be avoided as it will affect the accuracy of the ROM measurement

75. Goniometer alignment Center fulcrum of the goniometer over the palmar aspect of the first CMC joint. Align proximal arm with the ventral midline of the radius, using the ventral surface of the radial head and the radial styloid process for reference. Align distal arm with the ventral midline of the first metacarpal. In the beginning positions for flexion and extension, the goniometer will indicate an angle of approximately 30 to 50 degrees rather than 0 degrees, depending on the shape of the hand and wrist position. The difference between the beginning position degrees and the end-position degrees is the ROM. For example, a measurement that begins at 35 degrees and ends at 55 degrees should be recorded as 0–20 degrees.

76. Goniometer Alignment The goniometer alignment for measuring the beginning of carpometacarpal (CMC) extension range of motion is the same as for measuring the beginning of CMC flexion The alignment of the goniometer at the end of carpometacarpal (CMC) extension range of motion of the thumb. The examiner must be careful to move only the CMC joint into extension and not to change the position of the wrist during the measurement

77. THUMB: CARPOMETACARPAL ABDUCTION Plane - sagittal plane Axis - a medial– lateral axis Normal ROM - Normal ROM values for adults using the measurement methods presented in this book range from about 40 to 50 degrees. Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm midway between supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the CMC, MCP, and IP joints of the thumb in 0 degrees of flexion and extension. Stabilization - Stabilize the carpals and the second metacarpal to prevent wrist motions Normal END-FEEL - The end-feel is fi rm because of tension in the fascia and the skin of the web space between the thumb and the index fi nger . Tension in the adductor pollicis and fi rst dorsal interossei muscles also contributes to the fi rm end-feel

78. Goniometer alignment Center fulcrum of the goniometer over the lateral aspect of the scaphoid or radial styloid process, so that the proximal and distal arms of the goniometer can be properly positioned over the long axes of the first and second metacarpals. Align proximal arm with the lateral midline of the second (index) metacarpal, using the center of the second MCP joint for reference. Align distal arm with the dorsal midline of the first (thumb) metacarpal, using the center of the first MCP joint for reference.

79. Goniometer alignment At the beginning of carpometacarpal (CMC) abduction range of motion, the distal end of the individual’s first metacarpal of the thumb is in line with the second metacarpal of the index finger. The alignment of the goniometer at the end of carpometacarpal (CMC) abduction range of motion. The arms of the goniometer are correctly aligned with the first and second metacarpals, not the proximal phalanges

80. THUMB: CARPOMETACARPAL ADDUCTION Plane - sagittal plane Axis - a medial– lateral axis Normal ROM - average of about 15 degrees as measured between the thumb metacarpal and index metacarpal as the thumb passes dorsal to the palm. Testing position - same as abduction Stabilization - same as abduction Goniometer alignment - same as abduction Normal END-FEEL - same as abduction

81. THUMB: CARPOMETACARPAL OPPOSITION Normal rom - Mean axial ROM values vary from about 15 to 55 degrees measured at the metacarpal for motion isolated to the CMC joint, to about 70 to 90 degrees measured at the tip (nail) of the thumb, which includes MCP and IP joint motions Testing position - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination and the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation. Stabilization - Stabilize the fifth metacarpal to prevent motion at the fifth CMC joint and wrist. Normal END-FEEL – The end-feel may be soft because of contact between the muscle bulk of the thenar eminence and the palm or between the tip of the thumb with the base of the little finger. In some individuals it may be fi rm because of tension in the CMC joint capsule, fascia, and skin of the web space between the thumb and the index finger and tension in the adductor pollicis, first dorsal interossei, extensor pollicis brevis, and extensor pollicis longus muscles.

82. Goniometer is commonly not used to measure the angular range of the opposition. Instead, a linear ruler is often used to measure the shortest distance between the tip of the thumb and the center of the proximal digital crease of the little finger at the end of opposition Alternately, the shortest distance between the center of the proximal digital crease of the thumb and the distal palmar crease directly over the fifth MCP joint can be measured In this manner, motion at the MCP and IP joints of the thumb will not affect the measurement of opposition. In both methods the smaller the distance is between the landmarks, the greater the ROM will be.

83. Measurement Method: Linear Distance The range of motion (ROM) in opposition can be determined by measuring the shortest distance between the tip of the thumb and the proximal digital crease of the little finger. The examiner is using the arm of a goniometer to measure, but any ruler would suffice. This individual’s hand does not have full ROM in opposition Another method of measuring thumb opposition is to record the distance between the proximal digital crease of the thumb and the distal palmar crease over the fifth metacarpophalangeal (MCP) joint. This method avoids the inclusion of MCP and IP flexion of the thumb

84. THUMB: METACARPOPHALANGEAL FLEXION PLANE – frontal plane AXIS – anterior-posterior axis NORMAL ROM - values for adults vary from about 50 to 60 degrees. TESTING POSITION - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; the CMC joint of the thumb in 0 degrees of flexion, extension, abduction, adduction, and opposition; and the IP joint of the thumb in 0 degrees of flexion and extension STABILIZATION - Stabilize the first metacarpal to prevent wrist motion and flexion of the CMC joint of the thumb. NORMAL END-FEEL - The end-feel may be hard because of contact between the palmar aspect of the proximal phalanx and the fi rst metacarpal, or it may be fi rm because of tension in the dorsal joint capsule, the collateral ligaments, and the extensor pollicis brevis muscle.

85. GONIOMETER ALIGNMENT Center fulcrum of the goniometer over the dorsal aspect of the MCP joint. Align proximal arm over the dorsal midline of the metacarpal. Align distal arm with the dorsal midline of the proximal phalanx. The alignment of the goniometer on the dorsal surfaces of the first metacarpal and proximal phalanx at the beginning of metacarpophalangeal (MCP) flexion range of motion of the thumb. At the end of metacarpophalangeal (MCP) flexion, the examiner uses one hand to align the proximal arm of the goniometer. The examiner uses her other hand to maintain the proximal phalanx in flexion and align the distal arm of the goniometer.

86. THUMB: METACARPOPHALANGEAL EXTENSION PLANE – frontal plane AXIS – anterior-posterior axis NORMAL ROM - Normal MCP extension ROM for the thumb is usually considered to be 0 degrees, but some sources have reported 8 to 40 degrees depending on the measurement method.1 TESTING POSITION - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; the CMC joint of the thumb in 0 degrees of flexion, extension, abduction, and opposition; and the IP joint of the thumb in 0 degrees of flexion and extension. STABILIZATION - Stabilize the first metacarpal to prevent motion at the wrist and at the CMC joint of the thumb. NORMAL END-FEEL - The end-feel is fi rm because of tension in the palmar joint capsule, palmar plate (palmar ligament), inter-sesamoid (cruciate) ligaments, and flexor pollicis brevis muscle.

87. GONIOMETER ALIGNMENT Center fulcrum of the goniometer over the dorsal aspect of the MCP joint. Align proximal arm over the dorsal midline of the metacarpal. Align distal arm with the dorsal midline of the proximal phalanx. The alignment of the goniometer on the dorsal surfaces of the first metacarpal and proximal phalanx at the beginning of metacarpophalangeal (MCP) flexion range of motion of the thumb.

88. THUMB: INTERPHALANGEAL FLEXION PLANE - frontal plane AXIS – anterior-posterior axis NORMAL ROM - Normal ROM values for adults are reported to be about 80 degrees. TESTING POSITION - Position the individual sitting, with the forearm and hand resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; the CMC joint in 0 degrees of flexion, extension, abduction, and opposition; and the MCP joint of the thumb in 0 degrees of flexion and extension STABILIZATION - Stabilize the proximal phalanx to prevent flexion or extension of the MCP joint. NORMAL END-FEEL - Usually, the end-feel is fi rm because of tension in the collateral ligaments and the dorsal joint capsule. In some individuals, the end-feel may be hard because of contact between the palmar aspect of the distal phalanx, the palmar plate, and the proximal phalanx

89. GONIOMETER ALIGNMENT Center fulcrum of the goniometer over the dorsal surface of the IP joint. Align proximal arm with the dorsal midline of the proximal phalanx. Align distal arm with the dorsal midline of the distal phalanx The alignment of the goniometer at the beginning of interphalangeal (IP) flexion range of motion. The arms of the goniometer are placed on the dorsal surfaces of the proximal and distal phalanges. However, the arms of the goniometer could instead be placed on the lateral surfaces of the proximal and distal phalanges if the nail protruded or if there was a bony prominence or swelling The alignment of the goniometer at the end of interphalangeal (IP) flexion range of motion. The examiner holds the arms of the goniometer so that they maintain close contact with the dorsal surfaces of the proximal and distal phalanges.

90. THUMB: INTERPHALANGEAL EXTENSION PLANE – frontal plane AXIS – anterior-posterior axis NORMAL ROM - Normal active extension ROM at the IP joint of the thumb varies from about 20 to 30 degrees. Passive extension ROM has been found to be greater than active ROM. TESTING POSITION - Position the individual sitting, with the forearm and hand resting on a supporting surface forearm. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; the CMC joint of the thumb in 0 degrees of flexion, extension, abduction, and opposition; and the MCP joint of the thumb in 0 degrees of flexion and extension. STABILIZATION - Stabilize the proximal phalanx to prevent extension or flexion of the MCP joint. NORMAL END-FEEL - The end-feel is fi rm because of tension in the palmar joint capsule and the palmar plate (palmar ligament).

91. GONIOMETER ALIGNMENT - Center fulcrum of the goniometer over the dorsal surface of the IP joint. Align proximal arm with the dorsal midline of the proximal phalanx. Align distal arm with the dorsal midline of the distal phalanx In some individuals the angle of the nailbed may make it difficult to place the distal arm on the goniometer on the dorsal surface of the distal phalanx. In that case the axis of the goniometer should be centered over the lateral surface of the IP joint and the arms should be aligned with the lateral longitudinal axes of the proximal and distal phalanx. The alignment of the goniometer at the beginning of interphalangeal (IP) flexion range of motion. The arms of the goniometer are placed on the dorsal surfaces of the proximal and distal phalanges. However, the arms of the goniometer could instead be placed on the lateral surfaces of the proximal and distal phalanges if the nail protruded or if there was a bony prominence or swelling